STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10154 (07/08)
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STATEMENT OF IDENTITY FOR CHILDREN UNDER 18 YEARS OF AGE
This Statement may be used only to meet the new Medicaid/BadgerCare Plus/family planning services proof of identity rule for children under 18 years of age. This statement may not be used to meet the Medicaid/BadgerCare Plus /family planning services proof of citizenship rule. Instructions: In the space provided below, list all the children under age 18 in your household for whom you are a parent, guardian or caretaker relative. For each child you list, include the child's date of birth and place of birth (city, state and country). Complete, sign and return this statement to your local Medicaid/BadgerCare Plus office.
Child's Full Name (First, MI, Last) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Date of Birth
Place of Birth (City, State, Country)
Personally identifiable information will be used only for the direct administration of the Medicaid program. By signing this statement, I certify, under penalty of perjury and false swearing, that the information I have given is correct and complete to the best of my knowledge. I understand that the local agency may contact other persons or organizations, to confirm the accuracy of my statement. SIGNATURE (Parent, Guardian or Caretaker Relative) Print Name (Parent, Guardian or Caretaker Relative) Case Number Date Signed
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